Management of Specific Fractures

Question 1

What are the clinical signs of a fracture?

Answer 1

Pain
Swelling
Crepitus
Deformity
Adjacent structural injury:
Nerves/vessels/ligament/tendons

Question 2

What investigations can be done for a fracture?

Answer 2

X-ray

Question 3

How do you describe a fracture using X-ray?

Answer 3

Location: which bone and which part of bone?
Pieces: simple/multifragmentary?
Pattern: transverse/oblique/spiral
Displaced/undisplaced?
Translated/angulated?
X/Y/Z plane

Question 4

How do fractures Heal?

Answer 4

Bleeding - Blood

Inflammation - neutrophils/macrophages

New tissue formation - fibro, osteo, chondroblasts

Remodelling - Macrophages, osteoclasts, blasts

Question 5

What are the 3 stages of fracture healing?

Answer 5

Inflammation
Repair
Remodelling

Question 6

What happens during Inflammation?

Answer 6

Broken bones result in torn blood vessels and the formation of a blood clot or haematoma. The inflammatory reaction results in the release of cytokines, growth factors and prostaglandins, all of which are important in healing. The fracture haematoma becomes organised and is then infiltrated by fibrovascular tissue, which forms a matrix for bone formation and primary callus.
Hours/days

Question 7

What happens during Repair?

Answer 7

A thick mass of callus forms around the bone ends, from the fracture haematoma. Bone-forming cells are recruited from several sources to form new bone. Soft callus is organised and remodelled into hard callus over several weeks. Soft callus is plastic and can easily deform or bend if the fracture is not adequately supported. Hard callus is weaker than normal bone but is better able to withstand external forces and equates to the stage of “clinical union”, i.e. the fracture is not tender to palpation or with movement.
days-weeks

Question 8

What happens during Remodelling?

Answer 8

This is the longest phase and may last for several years. During remodelling, the healed fracture and surrounding callus responds to activity, external forces, functional demands and growth. Bone (external callus) which is no longer needed is removed and the fracture site is smoothed and sculpted until it looks much more normal on an x-ray . The epiphyses gradually realign and residual angulation may be slowly corrected.

Question 9

What happens in primary bone healing?

Answer 9

Intramembranous healing
Absolute stability
Direct to woven bone

Question 10

What happens in secondary bone healing?

Answer 10

Endochondral healing
Involves responses in the periosteum and external soft tissues
Relative stability
Endochondral ossification: more callus

Question 11

How long does it take for fractures to heal

Answer 11

3-12 Weeks depending on site

Signs of healing visible on XR from 7-10 days

Phalanges: 3 weeks
Metacarpals: 4-6 weeks
Distal radius: 4-6 weeks
Forearm: 8-10 weeks
Tibia: 10 weeks
Femur: 12 weeks

Question 12

What are the general principles of managing fractures?

Answer 12

Reduction - Closed, open

Hold - metal, no metal

Rehabilitate, Move, physiotherapy, use

Question 13

What are the principles for closed holding?

Answer 13

plaster

traction - skin/skeletal

Question 14

What are general fracture complications?

Answer 14

Fat embolus
DVT
Infection
Prolonged immobility (UTI, chest infections, sores)

Question 15

What are specific fracture complications?

Answer 15

Neurovascular injury
Muscle/tendon injury
Non union/mal union
Local infection
Degenerative change (intraarticular)
Reflex sympathetic dystrophy

Question 16

What are the factors that affect tissue healing?

Answer 16

Mechanical - movement, forces

Biological - Blood supply, Immune function, Infection, Nutrition

Question 17

What are causes of Fractured neck of femur?

Answer 17

Osteoporosis (older)
Trauma (younger)
Combination

Question 18

What would you do in an extra capsular NoF fracture?

Answer 18

minimal risk to blood supply and AVN: fix with plate and screws (Dynamic hip screw)

Question 19

What would you do in an intracapsular NoF fracture?

Answer 19

Intracapsular: if undisplaced: less risk to blood supply: fix with screws
If displaced: 25-30% risk AVN: replace in older patients; fix if young

Question 20

What is the presentation of a shoulder fraction?

Answer 20

often direct trauma
pain
restricted movement
Loss of normal shoulder contour

Question 21

What would be the clinical examination for a shoulder dislocation?

Answer 21

Assess neuromuscular status - axillary nerve

Question 22

What investigations would you do in a shoulder dislocation?

Answer 22

X-ray prior to manipulation, identify fracture e.g. humeral neck, greater tuberosity avulsion/glenoid.
Scapular Y view/modified axillary

Question 23

What is the management for a dislocated shoulder?

Answer 23

Vigorous manipulation should be avoided to prevent fractures.
Best method is traction/counter-traction and gentle internal rotation disimpact humeral head.
Make sure patient is relaxed + safe environment.

If alone use Stimson method

Question 24

What is the management for a distal radius fracture?

Answer 24

Cast - Temporary, reduction of fracture + placement into cast until definitive fixation.

MUA & K-wire - Fractures that are extra-articular + instability, especially in children, MUA in theatre + K-wire, remove wires post-op in clinic.

ORIF - Displaced, unstable fracture, open reduction internal fixation with plate + screws.

Question 25

When would treatment be non-operative for Tibial plateau fractures?

Answer 25

Truly undisplayed fractures with good joint line congruency assessed on CT/ high fidelity imaging.

Question 26

When would treatment be operative for Tibial plateau fractures?

Answer 26

Predominant

restoration of articular surface using combination of plate/screws.

Bone graft/cement may be necessary to prevent further depression after fixation

Question 27

What is the non operative management for an ankle fracture?

Answer 27

Non weight bearing below knee cast for 6-8 weeks, walking boot then physiotherapy to improve range of motion.

Weber A below syndesmosis & therefore though to be stable.

Weber B if no evidence of instability ( medial/posterior malleolus fracture and no taller shift)

Question 28

What is the operative management for an ankle fracture?

Answer 28

Soft tissue dependent - patient needs strict elevation due to injury swelling.

Open reduction internal fixation +/- syndesmosis repair using either screw or tightrope technique, screws can be left in situ but may break in time so will be removed

Weber B - unstable fractures - talar shift/medial or posterior malleoli fractures

Weber C - Fibular fracture above the level of the syndesmosis therefore unstable.